PY 2022 Quarterly Cost Share Technical Assistance Request for Payment

District *

Date * +

PY 2022 Master Agreement Contract Number
(If your 2022 MA has not yet been completed, please leave blank)

Period Covered by this request (select all that apply) *

1st Quarter {July 1, 2021 - September 30, 2021}

2nd Quarter {October 1, 2021 - December 31, 2021}

3rd Quarter {January 1, 2022 - March 31, 2022}

4th Quarter {April 1, 2022 - June 30, 2022}

Yearly {July 1, 2021 - June 30, 2022}

Submitted By: *

Title *

District Employee

County Finance

Email address *

Total Reimbursement Request:
*Please note - Salary and Operating are no longer required to be billed separately. *

If you would like salary and operating to be paid separately, please indicate below. (i.e. Salary paid to County and Operating paid to District) * 🛈

Salary

Operating

Upload County budget for your District (to show the salary and expenses paid out) *

Comments or Additional Information:

Please email Paula.Day@ncagr.gov or call 919-707-3786 with any questions or concerns.

Signature *

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